Faecal transplant may help relieve C. diff diarrhoea

A small new trial has concluded that inserting faecal material from a healthy person into the gut of someone with Clostridium difficile diarrhoea may cure their problem.

A small new trial has concluded that inserting faecal material from a healthy person into the gut of someone with Clostridium difficile diarrhoea may cure their problem more effectively than antibiotics.

In the study, reported online in the New England Journal of Medicine, one transplant of faecal material from a volunteer - with its mix of healthy bacteria - resolved severe diarrhoea in 13 out of 16 patients. Standard treatment with an antibiotic, in comparison, worked in four of 13 patients.

"This is the first hard evidence that has been provided for the treatment," senior author Dr Josbert Keller of the University of Amsterdam said.

"Those of us who do it know how effective it is," said Dr Colleen Kelly of Brown University's Alpert Medical School in Providence, Rhode Island, who was not connected with the study but uses faecal transplants in her practice.

The bacteria underlying the problem are called "difficile" for a reason. When it controls the gut, it can be difficult to eradicate. Antibiotics typically only work in 15% to 26% of patients with C. diff. - and after repeated rounds of treatment, the drugs become less effective.

"I've done 90 of these now in the last four and a half years. In patient after patient who has failed multiple courses of antibiotic, if you give them a dose of stool, they get better," said Dr Kelly.

Stool transplants have been proposed before as an alternative.

How the study was done

In the randomised trial by Dr Keller and his colleagues,13 patients with C. diff received vancomycin four times a day for 14 days. After 10 weeks, four were free of bacteria-related diarrhoea. Another 13 patients had the same drug therapy after bowel lavage. That worked in three cases.

The remaining 16 volunteers had a brief treatment with vancomycin, combined with bowel lavage, followed by the infusion of 500 mL of diluted donor faeces through nasoduodenal tube.

In the three cases where that treatment failed, the doctors re-treated patients with faecal material from a different donor. That worked in all but one case.

Among the volunteers in the non-transplant groups who had a relapse of C. diff, 18 were later given a faecal transplant. It cured 15 of them, although four of the 15 needed two treatments.

All of the donors - hospital employees not involved with patient care - were periodically screened for a variety of diseases.

When side effects were tallied in the transplant group, 94% reported diarrhoea, 31% had cramping and 19% had belching, but all of those symptoms disappeared within three hours. Nineteen percent ultimately reported constipation after treatment.

Faeces transplants may sound distasteful, but "the patients were desperate because they had had several episodes. There was nothing else they could do. There was no psychological hurdle for them," said Dr Keller.

"I think the 'yuck' thing is overplayed," Dr Kelly said. "There's a desperation when you're this sick this long."

Only eight of the 43 patients in the study were willing to try the treatment after their first relapse of C. diff, Dr Keller and his colleagues reported.

"The efficacy of antibiotic therapy decreases with subsequent recurrences, and it seems reasonable to initiate treatment with donor-faeces infusion after the second or third relapse," they wrote.

Ask the Expert

Dr Naayil Rajabally obtained his medical degree at the University of Witwatersrand in 2000. He completed his gastroenterology training in 2011 and subsequently completed his MPhil degree in Gastroenterology at the University of Cape Town. Dr. Rajabally has expertise and special interest in Crohn’s disease and ulcerative colitis.

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